Deprescribing plans a must for people with dementia given antipsychotic drugs

Doctors who place people with dementia on antipsychotic drugs should have in place a deprescribing plan to eventually end treatment to help reduce the widening use of these medications.

Antypsychotic drugs deprescribing dementia HammondCareDoctors who place people with dementia on antipsychotic drugs should have in place a deprescribing plan to eventually end treatment to help reduce the widening use of these medications. 

The Dementia Centre Head of Clinical Services A/Prof Stephen Macfarlane and HammondCare Dementia Centre Director A/Prof Colm Cunningham have written in the February edition of Australian Prescriber that older people are being prescribed antipsychotic drugs at a rate that dwarfs that of younger cohorts.

They say up to 44% of Australia’s aged care residents are on antipsychotic drugs, despite estimates that only 10% of this prescribing for people living with dementia is “appropriate”.

To better manage the use of these drugs, the two authors urge “deprescribing plans” be standard clinical practice to take effect after antipsychotics are prescribed and when symptoms settle.

“Deprescribing provides an ideal opportunity to try specific non-drug strategies for any behaviours that might re-emerge as the drug is withdrawn,” they write.

All members of the multidisciplinary team who participate in the person's care, including nurses and a pharmacist, should be involved in the development of the deprescribing plan.

The high rate of antipsychotic prescription in Australia is despite these medications being ineffective for many behaviours, and behavioural and psychological interventions being the preferred first-line treatments.

“These drugs are often prescribed for the management of the behavioural and psychological symptoms of dementia,” they write in the journal. “This is despite a lack of efficacy and high rates of adverse effects."

They note that research suggests a large proportion of antipsychotic prescribing occurs in the three months before someone enters aged care “and then increases markedly in the three months after admission”.

In the article Limiting antipsychotic drugs in dementia, A/Prof Macfarlane and A/Prof Cunningham write that many behaviours that can occur in dementia are unlikely to respond to pharmacotherapy at all. For example, there is no drug treatment for so-called “wandering” or calling out. No drug can be expected to modify behaviours such as shadowing staff, exit-seeking, disrobing or inappropriate voiding.

“The only means by which an antipsychotic may have efficacy is by sedating the person to the point where they are no longer able to engage in such behaviours. This constitutes chemical restraint,” they write.

Evidence of misuse of these medications as chemical restraint was presented during the Aged Care Royal Commission. The Commissioners in their Interim Report expressed concerns that recent regulatory changes would not be effective in reducing the use of psychotropic medications.

In Australia, risperidone is the only antipsychotic approved for the treatment of behavioural and psychological symptoms of dementia (BPSD) although there is data that suggest other antipsychotics are used “off label”.

A/Prof Macfarlane and A/Prof Cunningham note the adverse effect burden of antipsychotic drugs is significant and includes falls, sedation, extrapyramidal adverse effects and death.

They write that most BPSD will stop within several months, regardless of the prescription of antipsychotics.

It is important for multidisciplinary teams to identify what may be causing the BPSD and pursue non-drug psychosocial interventions as first-line treatment.

Common causes of symptoms include unrecognised or undertreated pain, depression and delirium.

HammondCare Chief Executive Mike Baird said the research behind this article highlights again the importance of a relationship-based approach, which is central to HammondCares’s model of care. “It values getting to know the person and tailoring psychosocial care strategies for unmet needs rather than quickly resorting to medication,” Mr Baird said.

The Commonwealth Government funds, through Dementia Support Australia (DSA), a three-level nationwide support service based on the needs of the person with dementia who is impacted by BPSD.

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